Professional Skills and Competence for Safe and Effective Procedural Sedation in Children: Recommendations Based on a Systematic Review of the Literature
Table 2
Drug-specific conclusions regarding the relation between professional competence/skills and PS-related safety.
Nr
Conclusion
Quality Level
Nontitratable drugs intended for moderate to deep sedation
(1)
During PS, intended to moderate or deep sedation, with the use of benzodiazepines, chloral hydrate, barbiturates, opiates, or combinations of these medicines, and during the subsequent recovery phase, there exists a variable but real risk of potentially serious drug-induced adverse events. Especially the risk for respiratory depression and/or airway obstruction necessitates specific skills and competence from the professionals in charge in terms of recognition and treatment.
Level 2
(B) Hoffman et al. 2002 [13], Pitetti et al. 2003 [32], Sanborn et al. 2005 [27], Cravero et al. 2006 [36],
Roback et al. 2005 [33], Newman et al. 2003 [34], Pena et al. 1999 [37], Mason et al. 2001 [38],
During PS using propofol, there is a real risk of potentially serious drug-induced adverse events. Especially the risk for respiratory depression and/or airway obstruction necessitates specific skills and competence from the professionals in charge in terms of recognition and treatment.
(c) Barbi et al. 2003 [12], Hertzog et al. 1999 [40], Hertzog et al. 2000 [41], Pershad and Godambe 2004
[42], Bassett et al. 2003 [43], Guenther et al. 2003 [44], Vespasiano et al. 2007 [29]
(2)
PS with propofol, including deep sedation, is equally safe in the hands of anesthesiologists and nonanesthesiologists if the latter are well trained and part of dedicated sedation team.
(C) Barbi et al. 2003 [12], Vespasiano et al. 2007 [29]
(3)
A deep PS using ketamine or propofol for examination of the upper airways, or for endoscopies of the upper gastrointestinal system, carries a real risk of potentially serious complications (i.e., laryngospasm and deep desaturation), which require specific skills and competence from the professionals in charge in terms of recognition and treatment.
Level 3
(C) Barbi et al. 2003 [12], Green et al. 2001 [45]
Ketamine
(1)
During PS using ketamine, there is a small but real risk of potentially serious drug-induced adverse events. Especially the risk for respiratory depression, airway obstruction and—infrequently—laryngeal spasm necessitates specific skills and competence from the professionals in charge in terms of recognition and treatment.
(C) Green et al. 2001 [45], Evans et al. 2005 [46], Meyer et al. 2003 [47], Cheuk et al. 2005 [48],
(2)
Independent risk factors for respiratory adverse events during a PS with the use of ketamine are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the coadministration of anticholinergics or benzodiazepines.
Based on a limited published experience on the use of dexmedetomidine for PS by experienced professionals, there seems to be a very small risk of potentially serious drug-induced adverse events. Respiratory events are extremely rare and hemodynamic adverse events (i.e., bradycardia and hypotension) are mostly clinically insignificant. Specific experience in dosing techniques, individual titration and avoiding dexmedetomidine in those patients who may not tolerate hemodynamic fluctuations seems to be associated with low risks.
Level 1
(A2) Koroglu et al. 2005 [49], Koroglu et al. 2006 [50]
(B) Mason et al. 2008 [51], Mason et al. 2008 [52]
(C) Berkenbosch et al. 2005 [53], Mason et al. 2006 [54], Ray and Tobias 2008 [55]
Remifentanil
(2)
During PS using remifentanil, there is a real risk of potentially serious drug-induced adverse events. Especially the risk for respiratory depression and/or airway obstruction necessitates specific skills and competence from the professionals in charge in terms of recognition and treatment.
PS with nitrous oxide is associated with an extremely low chance of serious adverse events. Instant discontinuation of gas flow in case of respiratory depression is the most important rescue intervention.
Nitrous oxide 70% causes significantly deeper sedation compared to nitrous oxide 50%. However, if embedded in a comprehensive sedation program there exists no significant difference in adverse events rates between both regimens.
